What are the treatment options for acute and chronic gout?

Treatment Options for Acute and Chronic Gout

Corticosteroids should be considered as first-line therapy for acute gout attacks in patients without contraindications because they are generally safer and a low-cost treatment option compared to other available therapies. 1

Acute Gout Treatment

First-Line Options (Choose Based on Patient Factors)

1. Corticosteroids

   • Preferred first-line due to safety profile and cost-effectiveness 1
   • Oral: Prednisone 0.5 mg/kg per day for 5-10 days 1
   • Intra-articular: Dose varies by joint size (effective for single joint involvement) 1
   • Intramuscular: Triamcinolone acetonide 60 mg 1
   • Contraindications: Systemic fungal infections 1
   • Adverse effects: Dysphoria, mood disorders, elevated blood glucose, immune suppression 1

2. NSAIDs

   • Use full FDA/EMA-approved anti-inflammatory doses 1
   • FDA-approved options: Naproxen, indomethacin, sulindac 1
   • Continue at full dose until attack completely resolves 1
   • Contraindications: Renal disease, heart failure, cirrhosis 1
   • Adverse effects: GI perforations, ulcers, bleeding 1

3. Colchicine

   • Only effective if started within 36 hours of symptom onset 1
   • Low-dose regimen: 1.2 mg followed by 0.6 mg 1 hour later 1
   • Continue with 0.6 mg once or twice daily until attack resolves 1
   • More expensive than NSAIDs or corticosteroids 1
   • Contraindications: Renal/hepatic impairment, drug interactions with CYP3A4 inhibitors 1
   • Adverse effects: Diarrhea, nausea, vomiting, abdominal pain 1

Combination Therapy

For severe attacks, particularly with multiple large joints or polyarticular involvement, consider initial combination therapy 1:

• Colchicine + NSAIDs
• Oral corticosteroids + colchicine
• Intra-articular steroids with any other modality

Chronic Gout Management (Urate-Lowering Therapy)

When to Initiate Urate-Lowering Therapy

Do not initiate long-term urate-lowering therapy after a first gout attack or in patients with infrequent attacks 1. Consider initiating therapy in patients with:

• Recurrent gout attacks
• Tophi
• Chronic gouty arthropathy
• Joint damage

First-Line Urate-Lowering Options

1. Allopurinol

   • Starting dose: 100 mg daily 2
   • Increase by 100 mg weekly until serum uric acid level ≤6 mg/dL 2
   • Typical maintenance: 200-300 mg/day for mild gout; 400-600 mg/day for tophaceous gout 2
   • Maximum dose: 800 mg daily 2
   • Dose adjustment for renal impairment:
     • CrCl 10-20 mL/min: 200 mg/day
     • CrCl <10 mL/min: ≤100 mg/day 2

2. Febuxostat (alternative when allopurinol is not tolerated)

   • Similar efficacy to allopurinol but higher cost 1
   • Adverse effects: Abdominal pain, diarrhea, musculoskeletal pain 1

3. Pegloticase (for refractory cases)

   • Reserved for chronic gout refractory to conventional therapy 3
   • Dosage: 8 mg IV infusion every two weeks 3
   • Monitor serum uric acid levels prior to infusions 3
   • Premedicate with antihistamines and corticosteroids 3
   • Risk of anaphylaxis and infusion reactions 3

Flare Prophylaxis During Initiation of Urate-Lowering Therapy

When starting urate-lowering therapy, provide prophylaxis with:

• Low-dose colchicine (0.6 mg once or twice daily) OR
• Low-dose NSAIDs with proton pump inhibitor if indicated 1

Duration of prophylaxis:

• At least 6 months, OR
• 3 months after achieving target serum urate (if no tophi), OR
• 6 months after achieving target serum urate (if tophi present) 1

Important Clinical Considerations

1. Do not interrupt urate-lowering therapy during acute attacks 1

2. Target serum urate level: ≤6 mg/dL 2

   • Normal serum urate: ~7 mg/dL for men and postmenopausal women; ~6 mg/dL for premenopausal women 2

3. Common pitfalls to avoid:

   • Using high-dose colchicine for acute attacks (increases toxicity without improving efficacy) 1
   • Stopping urate-lowering therapy during acute flares (worsens long-term outcomes) 1
   • Failing to provide flare prophylaxis when initiating urate-lowering therapy 1
   • Inadequate dosing of allopurinol (many patients need >300 mg/day) 2
   • Not adjusting allopurinol dose for renal impairment (increases risk of adverse effects) 2

4. Patient education:

   • Instruct patients to initiate treatment upon first signs of an acute attack 1
   • Maintain adequate fluid intake (at least 2 liters daily) 2
   • Limit consumption of purine-rich foods (organ meats, shellfish), alcoholic drinks (especially beer), and high-fructose corn syrup beverages 4
   • Encourage consumption of vegetables and low-fat dairy products 4

By following this algorithmic approach to gout management, clinicians can effectively control both acute attacks and prevent recurrent episodes, thereby reducing morbidity and improving quality of life for patients with gout.